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Request A Consultation

If you are facing surgery for any localized or locally recurrent cancer, you are welcomed to discuss your treatment with Dr. Evans. You can hasten this process by completing the Patient Referral Form below. You may copy this form and e-mail it to rae@richardaevans.com or fax it to 713-977-2716. We may need additonal information before scheduling your first appointment. Please call our office at 713-975-6270 after you have submitted this information.

Patient Referral Form

First Name
Last name
Street Address
City
State
Zip
Country
SSN (XXX-XX-XXXX)
Date of Birth MM/DD/YYYY
Gender Male Female
Daytime phone
Evening Phone
FAX
E-mail (required)

Your Diagnosis

Date of Diagnosis MM/DD/YYYY
Diagnosis Method
Specify if other

Your Treatment Information

Are you currently under treatment? YES NO
Treatment Method
Specify if other

We will review your insurance coverage and obtain additional demographic information. Medical and financial eligibility need to be established prior to confirming an appointment. If you would like to leave additional information, please type it here.

Support the Texas Cancer Center

  The Texas Cancer Center gratefully welcomes contributions from all those
who would like to support our mission. Please make your check payable to
the Texas Cancer Center and mail it to 1011 Augusta Dr., Suite 210,
Houston, Texas 77057. The Texas Cancer Center is a 501 (c) (3)
organization and all donations are fully tax deductible.

If your donation is in memory or in honor of an individual, please give
us an appropriate name and address so we may acknowledge your gift. We
would like to publicly acknowledge all gifts. If you wish to remain
anonymous, please let us know.

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